A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?

Monitor the client's temperature once every 6 hr.

Wear an N95 respirator when providing direct client care.

Make sure dietary plates and utensils are disposable.

Make sure the client's room has positive-pressure airflow.

Answer and Explanation

The Correct Answer is D

A. Clients in protective isolation require more frequent temperature monitoring due to their high risk for infection. Monitoring once every 6 hours may not be sufficient to detect early signs of infection.
B. An N95 respirator is necessary for airborne precautions (e.g., tuberculosis) but is not required for protective isolation unless indicated for another reason.
C. While disposable plates and utensils may be used, they are not a primary requirement for infection prevention in protective isolation. Properly cleaned and sanitized utensils are generally safe.
D. Protective isolation requires positive-pressure airflow to prevent airborne pathogens from entering the client’s room, reducing the risk of infection in immunocompromised individuals.

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Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"C"}}

Explanation

Pink-tinged urine:
- Indication of potential worsening condition
  Pink-tinged urine may indicate bleeding in the urinary tract, which could be a complication of the urinary tract infection (UTI) or another underlying issue.
Hct 45%:
- Indication of potential improvement
  The hematocrit has decreased from 50% to 45%, suggesting improved hydration status, as the previous elevated Hct was likely due to hemoconcentration.
Butterfly rash:
- Unrelated to diagnosis
  The butterfly rash is a hallmark sign of systemic lupus erythematosus (SLE), part of the client's medical history, but it is unrelated to the current UTI diagnosis.
Oxygen saturation 96% at 2 L/min via nasal cannula:
- Indication of potential improvement
  The oxygen saturation has improved from 95% on 3 L/min to 96% on 2 L/min, suggesting better respiratory status and gas exchange.
Blood pressure 100/50 mm Hg:
- Indication of potential worsening condition
  The blood pressure has decreased from 106/64 mm Hg to 100/50 mm Hg, which may indicate worsening perfusion or ongoing dehydration.
Disoriented to person, place, and time:
- Indication of potential worsening condition
  The client was previously oriented to person and place but is now disoriented. This could indicate worsening infection, progression to sepsis, or other complications such as hypoxia or electrolyte imbalance.

A. Teach assistive personnel how to apply restraints. B. Keep a padded tongue blade at the client's bedside. C. Maintain peripheral IV access. D. Pad the upper two side rails of the client's bed.

Correct Answer is D

Explanation

A. Restraints should not be used during a seizure, as they can cause injury. Instead, the focus should be on ensuring the client’s safety.
B. A padded tongue blade should never be used because forcing an object into the client’s mouth during a seizure can cause oral trauma or airway obstruction.
C. Maintaining IV access is beneficial for medication administration but is not a primary seizure precaution.
D. Padding the upper two side rails helps protect the client from injury during a seizure without restricting movement. This is a standard seizure precaution.

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A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"C"}}

Explanation

A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is D

Explanation

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